496804122-9-2-2025-21-AS-BMOS-DLBV4P-20250908160640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 09/02/2025
Date Signed: 09/02/2025 02:01:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2025 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250728132515

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496804122
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 29	DATE:	09/02/2025
		UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Lisa DiBartolo (Administrative Assistant)		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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-Facility staff are unlawfully confining resident to room.
-Facility staff are not adhering to resident care plan.
-Facility staff are not providing resident with oral hygiene.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Lisa DiBartolo, Administrative Assistant. Licensee, Alex Varshavsky was unable to come to the facility and was available via phone.

The Department received an allegation of facility staff are unlawfully confining residents to rooms. Per Reporting Party, on July 24, 2025, at approximately 10:30 AM, staff at an adult day program reported that a client tested positive for COVID-19. The facility subsequently tested all clients and sent them home. On July 25, 2025, residents (R1) disclosed that they were being locked in their room due to been positive for COVID-19 test results, regardless of R1 tested negative.

Continue on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250728132515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 09/02/2025

NARRATIVE

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Continued from LIC9099...

Based on interviews conducted with facility Administrative Assistant it was determined that the facility was notified that R1 was exposed to a person who had a positive test result for Covid19, then it was instructed by the Licensee to contact R1’s day program to obtain additional information and after three unsuccessful contacts, so the licensee advise staff to follow their facility protocol to isolate R1 in their room until it was clear if R1 was positive or not to ensure the health and safety of the residents in care, R1 was isolated in their room for three days as stated in their facility protocol as follow: “there shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others”. LPA was unable to find any supporting evidence that staff could or not have unlawfully confined R1 to their room due to contradictory information which it was not clear if resident was isolated or confined to their room due to Covid19 exposure. However, based on records review of facility daily care notes for the month of July, R1 was assisted with activities of daily living. A finding that the complaint allegation occurs of facility staff are unlawfully confining residents to rooms is unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation of facility staff is not adhering to resident care plans. According to the reporting party, R1 has a care plan that includes 1:1 supervision due to their high fall risk and dementia diagnosis, but on July 28, 2025, at around 9:10 AM, R1 was observed alone in their room without supervision. However, based on interviews conducted by LPA with the complainant it was revealed that they were under the impression that R1’s care plan included 1:1 supervision due to their diagnosis of dementia and higher fall risk, but there was no supporting evidence of such information in their agreement between the facility and R1’s responsible party. LPA obtained written communication between the facility and R1’s responsible party dated July 24, 2025, at 4:38pm regarding upcoming monthly payment increase effective August 1, 2025, due to significant increase of level of care to meet R1’s evolving needs including constant supervision due to high fall risk, two-person assistance for all transfers, wheelchair for mobility, total assistance with feeding (pureed diet), total assistance with toileting, showers, dressing, and personal hygiene, full medication management.

Continued on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250728132515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 09/02/2025

NARRATIVE

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Continued from LIC9099C...

Based on records, a review of R1’s care plan dated 7/2/25 confirmed above information detailing the need for an increase in supervision due to the high risk of falls through routine safety checks to be done. A finding that the complaint allegation occurs of facility staff is not adhering to resident care plans is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Regarding the allegation of facility staff are not providing residents with oral hygiene. The Reporting Party mentioned that R1 is not receiving assistance with oral care, such as brushing their teeth or flossing. It was reported by an outside party individual (I1) that R1 was observed regularly with a buildup of old food between their teeth. Based on interviews conducted with I1, who stated that due to the frequent occurrence of the incidents, they have not consistently documented when R1 has been observed with oral residue/leftover food in their mouth, but remarked that since R1 moved into Mirabel Lodge the lack of oral care has been a problem, which it has been discussed with Mirabel staff and administrative assistant who reminded the facility twice about R1’s physician order for "oral care after meals". Based on records review, R1’s physician report dated 7/21/25 confirms the above information. However, R1’s care notes for the month of July 2025 revealed some gaps mainly in the morning shift in R1’s oral hygiene as not been performed. Although, administrative assistant stated that the gaps found in the oral hygiene care notes were due to staff forgot to enter their initials in the log. Also, LPA conducted interviews with staff (S1, S2 & S3) who confirmed that the facility has a rotating schedule, and they indicated that they will assist R1 with oral hygiene when it was in their assigned group, but at times they will forget to fill in the care notes because they got busy with other duties assigned. A finding that the complaint allegation occurs of facility staff are not providing resident with oral hygiene is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025

LIC9099 (FAS) - (06/04)

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